Can Systematic Reviews of Child Protection contribute to knowledge transfer? Dr Sabine Maguire Senior Lecturer Child Health Cardiff University

Do we need SR in Child Protection? Baby P doctor under investigation Lawyers claim paediatrician failed to spot broken back and ribs during examination of boy two days before his death guardian.co.uk, November 2008guardian.co.uk, November 2008 Sir Roy Meadow struck off by GMC Sally Clark doctor wins GMC case

Legal aspects of Child Protection Family Courts Balance of probability Criminal courts Beyond reasonable doubt Kennedy report A doctor can be convinced, based on his or her experience, that a defendant is guilty - but unless there is compelling evidence supported scientifically, he or she should not express that view in criminal proceedings

Challenges of SR in physical abuse Varying definition of abuse (time/ country/ culture) Quality and paucity of evidence Lack of case control data Mixed fatal/non-fatal cases Reverse causality

Can you age bruises accurately with the naked eye? Ageing of bruises directly influences investigation of child abuse Numerous publications timetable of colour change in bruises to enable clear dating of injury Clinicians confident in ageing bruises – welcomed by police / courts

Inclusion and Exclusion Criteria Included All languages Ageing of bruises of any origin in children between 0-17 years Observational studies ( including case series) Excluded Review articles Expert opinion No details on confirmation of age of bruise Methodologically flawed

Ageing of Bruises SR: Methodology Panel of 15 reviewers ( paediatric, child protection expertise) Trained in Critical Appraisal, customised CAF based on NHS CRD standards 2 independent reviews all studies, 3 rd review to resolve differences Narrative summary

Included 3 ASSIA Caredata Child Data CINAHL Embase ISI Proceedings Medline Ovid MEDLINE In-Process & Other Non-Indexed Citations May 2010 Science Citation Index SIGLE Social Science Citation Index TRIP database Hand search of text books Hand search of all articles identified from other sources Scanning total titles & abstract for duplicates and relevancy 8102 Total articles reviewed 187 Translated 14 3 rd Review 80

Published evidence in relation to ageing of bruises Stephenson T, Bialas Y. ADC photos of 23 children, 36 bruises - observer estimate of age correct 24/44, Blue, brown, grey and purple days, Yellow - only after 1 day, 10/42 > 1 day Carpenter RF. ADC bruises in 22 children. Yellow only seen in bruises over 48 hours Bariciak ED, Plint AC, et al Pediatrics Red/blue, purple commoner 7days. Yellow/brown/green most often >7days, but seen in <48 hrs. Accuracy < 50%

Can You Age Bruises Accurately in Children? (with the naked eye) No!

Ageing – Important Pitfalls Different colours present in the same bruise at one time, Different areas, different colours Deep injury – delayed appearance Individual perception of colour is different (Munang et al, 2003) Ability to perceive yellow varies with age (Hughes et al, 2004)

Ageing of bruises: knowledge transfer SR published in ADC in 2005 Review findings initially rejected by practitioners Incorporated UK national guidance Citations ( google scholar/ Harzings publish or perish 2012) 71 Stimulated 11 publications aiming to identify a more scientific method of ageing of bruises

What radiological investigations should be performed to identify fractures in suspected child abuse? 34 studies included in original SR 2004 Key conclusion – single investigation ( skeletal survey or radionuclide bone scan) will miss occult fractures Results published 2006 – RCR/RCPCH National standards for Radiological Investigation Suspected Abuse – March 2008

What radiological investigations should be performed to identify fractures in suspected child abuse? Original SR – 2004 (34 included studies) Updates – 13 further studies Citations:39 studies ( to 2012) Current accepted practice – single investigation is inadequate Current research focusing on what is the optimal strategy for further Investigations

CAN SYSTEMATIC REVIEWS OF CHILD PROTECTION CONTRIBUTE TO KNOWLEDGE TRANSFER?

Systematic Reviews of Child Abuse Challenging to achieve internationally accepted Quality Standards for SR Results may not endorse well established practice Drives a higher quality research agenda Establishes state of current evidence for Medical practitioners, Investigating agencies and Legal practitioners

Core Info Cardiff Child PrOtection Systematic REviews Please visit our newly-launched site: